Few studies have reported the incidence or prevalence of cracked teeth with pulpal involvement. No attempts have been made to evaluate the prevalence or clinical predictors for intrapulpal cracks. The purpose of this study was to investigate the prevalence of intrapulpal cracks in first and second mandibular molars and to determine if clinical findings are predictive for the existence of intrapulpal cracks. First and second mandibular molars (190) requiring non-surgical root canal treatment at the VCU Graduate Endodontic Practice between February 15, 2013 and August 15, 2013 were analyzed retrospectively. Teeth were transilluminated, stained, and inspected for intrapulpal cracks using a dental microscope. Data gathered included: demographics, subjective and objective information regarding the chief complaint to include bite stick test, transillumination, probing depths greater than 4mm, existing restorations, and diagnosis. Chi-square and logistic regression were performed (p<0.05). The prevalence of intrapulpal cracks in first and second mandibular molars combined was 9% (17/190, 95%CI= 5.7% to 13.9%). The prevalence was 7% for 1st molars and 13% for 2nd molars. There was no statically significant difference in the prevalence between first and second mandibular molars. Individual characteristics predictive for the existence of intrapulpal cracks were age, probing depth greater than 4mm, transillumination and a positive Tooth Slooth™ test (all p<0.05). Staining of the pulp chamber after access identified only one of 17 intrapulpal cracks. Staining of the pulp chamber did not significantly increase the ability to identify intrapulpal cracks. Neither diagnosis, sex, nor existing restorations were significant predictors for intrapulpal cracks. Probing depth greater than 4mm, age over 40 and a positive Tooth Slooth™ test were conjointly significant for predicting intrapulpal cracks.

Critically ill patients who require MV are at risk for a number of complications, including the development of ventilator-associated events (VAE) and agitation that may require the use of sedation. Patients experience anxiety and discomfort during mechanical ventilation from a variety of sources including unfamiliar breathing assistance and an inability to communicate anxiety and pain verbally, but a primary cause of discomfort identified by these patients is the simply the presence of the endotracheal tube (ETT). Discomfort often leads to agitation and may be exacerbated by ETT movement. Management of agitation typically involves the use of sedative therapy and has been shown to increase the length of stay in the hospital. Additionally, when ETT cuff pressure is not adequately maintained, risk of microaspiration increases and these microaspirations increase the risk of ventilator-associated events. ETT movement may adversely affect the cuff seal against the tracheal mucosa, increasing leakage around the cuff and microaspiration. To date, no studies have described the effect of ETT movement on patient comfort and agitation. Noting the frequency of ETT movement during the provision of nursing care and plausible inadvertent consequences on discomfort and agitation, a research model was created and specific instruments selected in order to study this topic. This dissertation will provide a review of the literature regarding the role of the ETT in microaspiration, as well as detail a study that explores the frequency and amount of ETT movement and its potential effect on agitation.

Clinicians and researchers know that women experience distress related to the diagnosis of and treatment for ovarian cancer. A review of the literature revealed that while there is interest in the topic, distress is inconsistently defined and measured. Women have been reported to have a variety of distress experiences including the challenges of late diagnosis and the treatment regimen, communication difficulties with healthcare providers, and concern about the effect of their diagnosis on their loved ones. Without information directly from women, assumptions predominate about what the experience is like and what they would find helpful from support persons. Women’s perceptions about distress was identified as a gap in the knowledge leading to the present study which asked “What do women with ovarian cancer want their spouse/significant other, family, friends, and healthcare providers to know about their experience of distress during diagnosis and treatment?” A qualitative method, Grounded Theory as outlined by Glaser and Strauss in 1967 was chosen to guide this IRB approved study. Twelve women participated in audiotaped interviews contributing data for analysis using the constant comparative method. Six common themes or subcategories emerged across all the interviews and resulted in a conceptualization of the experience as an “existential assault.” Though individual experience differed, abstraction and conceptualization of the data revealed the common themes as (a) “out of the blue like lightning”; (b) “no stone left unturned”; (c)“knowing what I don’t want to know and not knowing what I want to know”; (d) “watching you, watching me- we are both afraid”; (e) “talking yet not talking, about death”; and (f) “now I have to take care of me.” Participants expressed the need for professional support people who contribute their efforts to cure, but who also listen to the participant’s need to manage and control their own experience and to live in ways that give their life meaning and purpose. The experience of distress for the participants was intensified by the needs of those in their social network (spouse/significant other, family, friends, and healthcare providers) who also experienced distress, at times requiring participants to provide support for those who would be expected to be providing support.

Introduction: The potential benefits of collaborative goal setting in the clinical setting have been shown. However, we have a limited understanding about what needs to have transpired between a patient and his or her clinician for them to report that they engaged in collaborative goal setting. Therefore, our ability to monitor and foster collaborative goal setting remains limited. Methods: My three-manuscript dissertation used a mixed-methods approach utilizing both qualitative and quantitative research methods. The aims of my study were to: (1) develop a conceptual model of collaborative goal setting as perceived by patients; (2) generate a list of survey items for possible inclusion in a measure of collaborative goal setting, using results from patient focus groups and input from an expert panel; and (3) administer the collaborative goal setting measure to a sociodemographically diverse sample of patients with diabetes and test the psychometric properties of the measure. Results: Study 1 found that patients described collaborative goal setting as containing four distinct domains that occurred within the context of a caring relationship with their health care provider: (1) listen and learn from each other; (2) share ideas honestly; (3) agree on a measurable objective; and (4) support for goal achievement. Patients also articulated clear responsibilities for themselves and their clinicians within each domain and described collaborative goal setting as a process that occurs over time. Study 2 found that the second-order factor analysis supported the proposed measurement structure of a 37-item measure of patient-perceived collaborative goal setting. Overall model fit of the first-order model was good (χ = 4366.13, p<.001; RMSEA = .08). The internal consistency of the second-order model scales [caring relationship, listen and learn, share ideas, agree on a measurable objective, and support for goal achievement] were very high (α = .89-.94) as was the reliability (Mcdonald’s Ώ = .819). Study 3 found that the only significant pathway was the relationship between collaborative goal setting and self-management, which was partially mediated by self-efficacy (p<.05). After controlling for a variety of socio-demographic characteristics, the partial mediation model with self-efficacy was no longer significant (p=.055), however, the direct effects remained significant: self-management and collaborative goal setting (p<.001) and self-efficacy (p<.001), as well as self-efficacy on collaborative goal setting (p<.05). Discussion: Findings from these three studies support the new measure of collaborative goal setting developed from patient perceptions of this process.

Anesthesia patient handoffs are a vulnerable time for patient care and handoffs occur frequently during anesthesia care. Communication failures contribute to patient harm during anesthesia patient handoffs. The Joint Commission has recognized the potential for communication failure during patient handoffs and has recommended processes to improve handoff safety. Handoffs are made more difficult by latent conditions such as time constraints, pressure and distractions, which often result in incomplete or inaccurate handoff reports. This nonexperimental, correlation study identified the latent conditions that occur during the handoff process and their relationship to the quality of the handoff. This research shows an inverse relationship between latent conditions and anesthesia patient handoff scores. The number of latent conditions and the types of latent conditions affected handoff scores. Handoffs that were not interactive or handoffs with unsafe timing predictably resulted in poor handoff communication. Clinicians must acknowledge that handoffs are a high-risk event that can result in patient harm. Clear and effective communication is key to safe, quality care and this includes being aware of and minimizing the impact of latent conditions during the anesthesia patient handoff.

Craniosynostosis is a disorder characterized by the premature fusing of cranial sutures in an infant. Premature closure of these sutures can lead to detrimental consequences on the development of a child. The two broad categories of craniosynostosis are classified as syndromic and nonsyndromic. Nonsyndromic craniosynostosis involves only the fusion of one or more sutures, whereas syndromic craniosynostosis involves other abnormalities throughout the body of the affected individual. Two of the families analyzed in this study were of the syndromic nature, and known FGFR mutations were discovered. However, phenotypical features documented in association with these mutations differed from our individuals. Two families affected with nonsyndromic sagittal synostosis were also analyzed. Within one of these families, three candidate mutations were identified as possible disease causing mutations. These mutations were found in the genes ITGAV, SLC30A9, and BAMBI. Here we analyze the function of these proteins and determine the significance of the role they may play in nonsyndromic craniosynostosis.

The purpose of this study was to determine if a relationship existed between the change in serum osmolality in the chronic renal failure patient on hemodialysis and the number of clinical symptoms of the dialysis disequilibrium syndrome experienced during hemodialysis. The study was conducted at the Renal Dialysis Unit of an urban medical center located in a southeastern city. Data were collected from May 25, 1978 to June 30, 1978. Data were obtained during 28 hemodialysis procedures performed on 11 subjects. Serum osmolality measurements were collected prior to initiation of the dialysis procedure, at half-hour intervals during dialysis, and prior to termination of dialysis. Clinical symptoms which occurred during dialysis were recorded by the patients and nursing personnel. The hypothesis was that the number of clinical symptoms of the dialysis disequilibrium syndrome experienced by the chronic renal failure patient during hemodialysis will increase as the serum osmolality decreases.

Medicaid orthodontic patients have been shown to miss more appointments and break more appliances than self-pay patients, indicating a greater tendency toward non-compliance. Lack of compliance during the post-treatment phase can be detrimental to retention. The purpose of this study was to determine whether there is a difference in PAR score changes between Medicaid and non-Medicaid patients during and after orthodontic treatment. PAR scores were determined using study models of 43 Medicaid and 39 non-Medicaid patients before and at the end of active treatment, and 24 Medicaid and 42 non-Medicaid patients at the end of treatment and at an average of 13 months post-treatment. PAR scores generally reduce during treatment and will increase if relapse occurs. Rates of PAR score change during and after treatment were compared between Medicaid and non-Medicaid patients using the Mann-Whitney U-test. The mean initial PAR score was greater in the Medicaid group (31.95 versus 23.28; p=0.003) while there was no significant difference found between the two groups for the end of treatment PAR scores (3.22 versus 2.93; p=0.451). The rates of PAR score improvement during treatment (14.07/year versus 12.14/year; p=0.203) and worsening after the removal of orthodontic appliances (2.04/year versus 2.91/year; p=0.872) were found not to differ between the two groups. It was found that the rate of PAR score improvement during treatment did not differ between Medicaid and non-Medicaid patients. During the post-treatment period, the rate of PAR score worsening was also found not to differ.

OBJECTIVE: To investigate the relationship between Medicare Managed Care (MMC) penetration and percentage of disability in older adults (individuals age 65 and older). Considering disability as an indicator of one or more unsuccessfully managed chronic diseases, this study investigates the assumption that managed care improves coordination of care, as well as access to preventive care. If managed care’s mandate is being met, then it should be evidenced in decreased prevalence of older adult disability. METHOD: Taking an ecological approach, this study used data from the Agency for Healthcare Research and Quality (AHRQ, 2003) to compare the percentage of older adult disability in counties from 30 states and the District of Columbia with high and low MMC penetration. Covariates representing various aspects of community context were introduced into a final multivariate linear regression to examine whether MMC penetration was a significant predictor of countywide percent of older adult disability. RESULTS: While MMC penetration was a significant predictor of prevalence of older adult disability in a bivariate analysis (r=-0.197, p < .001), it lost its significance in the final multivariate model. CONCLUSION: While this study does not demonstrate a relationship between MMC penetration and prevalence of older adult disability, it is possible that MMC, once fully implemented under the 2003 Medicare Prescription Drug, Improvement, and Modernization Act, could lead to reduced prevalence of disability.

Stroke is the most common cause of acquired epilepsy in persons 35 and older. The massive increase in extracellular glutamate during stroke causes a cascade of intracellular events that can lead to cell death or the molecular changes that initiate the development of epilepsy. In addition, many studies point to a modulatory role of the endocannabinoid system in controlling seizures. Animal models of stroke induced acquired epilepsy have been difficult to develop. Therefore, this dissertation was initiated to develop an organotypic hippocampal slice culture model of acquired epilepsy and examine the changes in distribution and function of the endogenous CB1 receptor system. We utilized 4-aminopyridine and glutamate to induce separate excitotoxic injuries to slice cultures. Both injuries produced significant cell death acutely following the injury. After a latency period, we observed a significant increase in the number of slice cultures that displayed electrographic seizures in both injury models. Western blot analysis demonstrated that the cannabinoid CB1 receptor protein was significantly upregulated following injury with glutamate. Immnohistochemical studies demonstrated that this receptor upregulation was likely specific to the glutamatergic terminals. Electrophysiological experiments were performed to study endocannabinoid modulation of inhibitory and excitatory signaling in the CA3 pyramidal cells. We demonstrated that depolarization induced suppression of excitation (DSE) was enhanced in slice cultures that had undergone glutamate injury. This indicated that the upregulation of CB1 receptors following glutamate injury was physiologically functional, as it enhanced cannabinoid control of the excitatory signaling. These studies support the hypothesis that there is a functional alteration of CB1 receptors in the epileptic state that acts to suppress seizures. The development of an organotypic hippocampal slice culture model of stroke acquired epilepsy provides a unique tool to study the neuronal plasticity changes associated with epileptogenesis. It also provides a practical model to study pharmacological agents that may be useful in preventing or treating epilepsy.